Provider Demographics
NPI:1952723215
Name:KRISTIAN C. DIETZ, DDS, PLLC
Entity Type:Organization
Organization Name:KRISTIAN C. DIETZ, DDS, PLLC
Other - Org Name:BRIGHT RIDGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:479-715-4277
Mailing Address - Street 1:1603 SW REGIONAL AIRPORT BLVD.
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712
Mailing Address - Country:US
Mailing Address - Phone:479-715-4277
Mailing Address - Fax:
Practice Address - Street 1:1603 SW REGIONAL AIRPORT BLVD.
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:479-715-4277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR39131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty